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    v1.0.31
    OpenPayerPolicy UpdatesDurable Medical Equipment (DME)North Dakota Medicaid CPM Coverage | OpenPayer
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    CurrentNorth Dakota Department of Health & Human ServicesPolicy N/A

    Continuous Passive Motion Exercise (CPM)

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    This policy governs Medicaid coverage, prior authorization, documentation, and limitations for continuous passive motion exercise equipment following total knee replacement.

    Policy Summary
    PayerNorth Dakota Department of Health & Human Services
    PolicyContinuous Passive Motion Exercise (CPM)
    Policy CodePolicy N/A
    Change TypeDocumentation clarification
    Effective DateMarch 1, 2007
    Next Review DateN/A
    Key ActionObtain service authorization for continuous passive motion exercise equipment.
    SourceLink
    POLICY UPDATE CHANGES

    Documentation requirements were clarified to include a prescribing physician or practitioner prescription, an examination within 90 days of the service authorization start date, and documentation addressing medical necessity.

    E0935Covered CPM equipment code
    2 daysStart device use after surgery

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    3 weeksMaximum use after surgery
    90 daysExamination timing before authorization
    YesService authorization required

    Initial CPM Coverage

    Initial CPM coverage

    Covered when all of the following are met:

    CPM coverage criteria

    • Clinical and timing criteria

      • Indication: Member has undergone total knee replacement.
      • Initiation timing: Use of the device starts within two days following surgery.within two days following surgery
      • Duration limit: Use is allowed for a maximum of three weeks from the date of surgery.three weeks maximum from the date of surgery

    CPM treatment started during hospitalization is excluded from DME coverage because the treatment is covered as part of the member’s hospital stay.

    Covered Equipment and Timing Limits

    Covered CPM CodeHCPCSCovered
    E0935Continuous passive motion exercise device for use on the knee
    Postoperative initiation
    Required start timeWithin two days following surgery
    Covered equipmentContinuous passive motion exercise device for use on the knee (E0935)
    Qualifying surgeryTotal knee replacement
    Maximum duration
    Maximum covered durationThree weeks maximum from the date of surgery
    Duration measured fromDate of surgery
    Covered equipment

    Authorization and Coverage Safeguards

    Prior Authorization

    Prior Authorization Required

    Service authorization is required before CPM equipment is provided. Obtain authorization for the CPM service in accordance with North Dakota Medicaid requirements.

    Documentation Required

    Surgery and Prescription Documentation

    Submit documentation identifying the type of knee surgery, surgery date, CPM application date, hospital discharge date, and a prescription from the prescribing physician/practitioner. The prescribing physician/practitioner must examine the member within 90 days before the service authorization start date and document medical necessity; supplemental documentation from other disciplines may be included as additional support.

    • Type of knee surgery performed
    • Date of surgery
    • Date the CPM was applied
    • Date of hospital discharge

    Continuous Passive Motion Overview

    Continuous passive motion (CPM) uses a device to passively move the joint after surgery. Under this policy, coverage is limited to knee use following total knee replacement, with treatment subject to postoperative timing limits.

    Knee CPM Medical Necessity

    Knee CPM medical necessity

    CPM is medically appropriate when all of the following are met:

    CPM medical necessity

    • Surgical indication: Total knee replacement has been performed.
    • Anatomic use: The device is used on the knee only.knee only
    • Start of treatment: Device use starts within two days following surgery.within two days following surgery

    Required Supporting Documentation

    Documentation Required

    Submit operative and treatment timing information

    Submit documentation identifying the type of knee surgery performed, date of surgery, date of CPM application, and date of hospital discharge.

    Documentation Required

    Submit the required prescription

    A prescription from a prescribing physician or practitioner is required.

    Documentation Required

    Submit examination and medical necessity documentation

    Submit documentation of a physician or practitioner examination performed within 90 days of the service authorization start date. The physician or practitioner's documentation must address medical necessity.

    Excluded CPM Treatment

    CPM treatment started during hospitalization is not covered through DME; it is covered as part of the member’s hospital stay.

    Policy Summary
    PayerNorth Dakota Department of Health & Human Services
    PolicyContinuous Passive Motion Exercise (CPM)
    Policy CodePolicy N/A
    Change TypeDocumentation clarification
    Effective DateMarch 1, 2007
    Next Review DateN/A
    Key ActionObtain service authorization for continuous passive motion exercise equipment.
    SourceLink
    On This Page
    Initial CPM CoverageCovered Equipment and Timing LimitsAuthorization and Coverage SafeguardsContinuous Passive Motion OverviewKnee CPM Medical NecessityRequired Supporting DocumentationExcluded CPM Treatment
    Continuous passive motion exercise device for use on the knee (E0935)
    Physician or practitioner examination
    Examination timingWithin 90 days of the service authorization start date
    Required examinerPhysician or practitioner
    Documentation purposeThe physician or practitioner's documentation must address medical necessity
  1. Prescription from a prescribing physician/practitioner
  2. Physician/practitioner examination within 90 days of the service authorization start date
  3. Physician/practitioner documentation addressing medical necessity
  4. Supplemental documentation from other disciplines, if available
    5. Documentation Required

    Medical Necessity Documentation

    The physician/practitioner documentation must support the medical necessity of the CPM service. An examination must occur within 90 days of the service authorization start date.

    • Document the clinical rationale and medical necessity for CPM.
    • Include supplemental documentation from other disciplines when it provides additional support.
    Denial Risk

    Hospital-Started CPM Not Covered Through DME

    CPM treatment started during a hospitalization is not covered through DME because it is covered as part of the member’s hospital stay.

    • Do not bill hospital-started CPM treatment through DME.
    Denial Risk

    Coverage Timing and Indication Requirements

    Coverage is limited to CPM use on the knee (E0935) following a total knee replacement. The device must be started within two days after surgery, and coverage is allowed for a maximum of three weeks from the surgery date.

    • Use on the knee only (E0935).
    • Total knee replacement is required.
    • Device use must start within two days following surgery.
    • Maximum covered duration is three weeks from the date of surgery.
    Treatment duration: Use does not exceed three weeks from the date of surgery.three weeks maximum from the date of surgery
    Note

    Include supplemental supporting documentation

    Supplemental documentation from other disciplines may be submitted as additional supporting documentation.